The Rehabilitation Center Of Albuquerque
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 5900 Forest Hills Drive Ne, Albuquerque, New Mexico 87109
- CMS Provider Number
- 325034
- Inspections on file
- 25
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at The Rehabilitation Center Of Albuquerque during CMS and state inspections, most recent first.
Two residents experienced significant changes in condition without appropriate notification of their POA/emergency contacts or providers. One resident with complex neurologic and vascular diagnoses had multiple documented CIC events, including abnormal vitals with unresponsiveness, seizures, falls with head injury, COVID‑19 infection, swallowing difficulties, and an altercation, yet staff consistently notified only a resident representative who was not the POA, despite clear documentation that the spouse and then the son were to be notified first. Another resident with dementia, chronic respiratory failure, CHF, and hypoglycemia, and designated as full code, developed mouth breathing with gurgling, low O2 saturation requiring increased oxygen, abnormal lung sounds, and decreased responsiveness; the nurse placed this information in a non‑emergent provider log instead of directly contacting a provider or EMS. Later that morning, staff found the resident unresponsive, initiated CPR, and a code blue was called, with the DON and NP confirming that no provider notification had occurred despite the clear CIC.
Two residents experienced deficiencies in care when staff did not follow physician orders for oxygen therapy and STAT diagnostics. One resident with COPD and acute respiratory failure had orders for continuous O2 at 5.5 LPM via nasal cannula, yet was repeatedly observed with the portable O2 device turned off or set below the ordered flow, without a nasal cannula attached, and with an empty portable tank, resulting in low O2 saturations on room air. Staff acknowledged the resident required assistance with O2 therapy, and a CNA reported removing the nasal cannula and not replacing it. Another resident recovering from a right femur fracture developed severe left knee pain with swelling and decreased range of motion; an after-hours provider ordered STAT CBC, CMP, CRP, and a STAT left knee X-ray, but these were not completed because the orders were not documented correctly, causing a delay. The DON confirmed that O2 was not provided as ordered and that STAT labs and imaging were not obtained immediately due to documentation errors.
A resident with an abdominal surgical incision and orders for daily wound care did not receive the prescribed cleansing, packing with antimicrobial dressing, and foam covering for several consecutive days, despite the TAR indicating treatments were completed. When the dressing was finally changed, staff noted increased drainage, redness, and purulent discharge, and a subsequent wound culture was positive for gram negative and gram positive bacteria, including MRSA. The resident reported the dressing had not been changed for several days, and the IP/Unit Manager and DON confirmed that ordered wound care had been missed and not performed as prescribed.
Surveyors found that a treatment cart and a medication cart on the 300 unit were left unlocked and unattended, with access to wound care supplies, scissors, topical creams, multiple oral medications (including Buspirone, Glipizide, Mirtazapine, Venlafaxine, Carbamazepine, Gabapentin, Colace), eye drops, and lancets. An LPN responsible for the carts confirmed they were open and acknowledged they should be locked when not in use, and the DON stated that medication and treatment carts are expected to remain locked and attended to prevent resident access and potential injury.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. For one resident with an abdominal surgical wound, the TAR showed wound care as completed each shift, but progress notes and a communication form later revealed the dressing had not been changed for several days, with increased drainage, redness, purulent discharge, and a culture positive for gram negative and gram positive bacteria. For another resident who experienced a CIC, vital signs taken afterward were not documented in the EHR. The DON confirmed that wound care documentation on the TAR was inaccurate and that the vital signs following the CIC were not entered as required.
A resident was admitted with multiple diagnoses, including a right femur fracture, DM2, cognitive communication loss, and right hip pain, but the baseline care plan developed within 48 hours addressed only skin integrity of the right hip after surgery. The plan omitted other necessary care areas and diagnoses, such as ADLs, fall risk interventions, advanced directives, and diabetic management. A UM confirmed that the baseline care plan was incomplete and did not reflect the minimum healthcare information needed to guide immediate care.
A transport driver violated facility policy by soliciting and accepting $100 from a cognitively intact resident during a bank trip, after repeatedly mentioning personal financial needs. The driver did not repay the money, and the incident was discovered when the resident reported the situation to staff.
A medication error involving a resident with morbid obesity and DM2 was not reported to the State Agency as required by facility policy. The Administrator confirmed the lack of reporting, citing staff turnover, DON absence, and operational challenges as contributing factors.
A resident with diabetes and obesity was given two doses of Mounjaro within 24 hours due to staff administering the wrong injection, confusing it with a similar-looking migraine medication stored in the same refrigerator. The error was compounded by the electronic MAR prompting for the medication and failure to carefully read the label. After the incident, only routine blood sugar checks were performed, with no additional monitoring or documentation of symptom assessment.
A medication cart was found unattended and unlocked in a hallway, with narcotics secured in a locked box but other medications accessible. An RN confirmed leaving the cart unlocked while stepping away, and the interim DON stated that all carts are expected to remain locked to prevent unauthorized access.
A resident's room had a broken wall with a hole that was not reported or repaired by staff. The issue was not documented in the facility's maintenance system, and staff, including a CNA, Maintenance Director, DON, and Administrator, were unaware of the damage until it was observed during a survey. The resident stated the hole had been present since moving in and had not been reported.
A resident with a g-tube did not receive medications according to physician orders and professional standards. The RN administered three medications simultaneously without flushing the tube before or after, as captured on video. The DON confirmed the RN's failure to adhere to the required procedures.
A resident with a history of seizures missed multiple doses of levetiracetam, leading to breakthrough seizures and an emergency hospital transfer. The facility failed to notify the physician about the missed doses, and the medication was available in an alternative form that was not used.
A resident with a history of seizures missed three doses of levetiracetam due to the medication not being available in the cart, leading to breakthrough seizures and emergency medical intervention. The medication was available in the facility's Omnicell but was not utilized.
The facility failed to serve food under sanitary conditions, with multiple residents reporting cold and unappetizing meals. Observations revealed that both hot and cold foods were not maintained at safe temperatures, and the Dietary Manager acknowledged that food carts often sat in the halls for extended periods before delivery.
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, unappetizing, and sometimes even raw. An observation of a test tray revealed that the green beans were unseasoned and cold, the cheese quesadilla was cold with unmelted cheese, and the pineapple pieces and beverage were warm. The Dietary Manager acknowledged that food carts sitting in the halls for extended periods could contribute to these issues.
The facility failed to ensure accurate insulin use information in MDS assessments for two residents. The assessments indicated insulin administration, but physician's orders and MARs did not support this information. The MDS nurse confirmed the error.
The facility failed to properly store medications in medication carts, resulting in loose medications being found under the medication cards. Observations revealed loose tablets and capsules in the 300 and 400 hall medication carts. The DON confirmed that loose medications are not allowed and staff should check for them daily.
The facility failed to accommodate the dietary preferences of two residents, leading to emotional distress and unmet nutritional needs. One resident did not receive the meals she ordered, while another vegetarian resident was served meat due to miscommunication.
The facility failed to support residents in ADLs by not offering showers according to schedule and not answering call lights in a timely manner. A resident reported not having a shower since admission and not knowing her shower schedule, while another did not receive showers due to staff shortages. Additionally, residents experienced long wait times for call light responses, with one waiting about an hour and another waiting 22 minutes for assistance.
The facility failed to serve food according to the presented menu, leading to residents receiving incorrect meals. One resident received Salisbury steak instead of the posted menu items, and another vegetarian resident was served meat despite their dietary preference being documented.
A resident's call light was found to be non-functional, and despite the resident informing multiple staff members, no action was taken to repair it. The facility's maintenance records showed no work order for the issue, and the Administrator confirmed the oversight.
A resident with multiple respiratory and cardiovascular conditions was observed using oxygen therapy without proper documentation of physician orders and without labeled oxygen tubing and humidifier. Staff confirmed that the equipment should be labeled and orders should be documented upon admission, which was not done in this case.
Failure to Notify POA and Providers of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify resident representatives and providers of significant changes in condition for two residents. For one resident with traumatic hemorrhage of the right cerebrum, carotid artery aneurysm, convulsions, and a cognitive communication deficit, the face sheet and POA documents identified the spouse as POA and first emergency contact, and the son as second emergency contact and secondary POA. Social services documentation and nursing notes showed that this resident explicitly stated that her husband should be the first person notified of any changes in condition and her son the second. Despite this, multiple SBAR forms documented repeated changes in condition, including abnormal vital signs with unresponsiveness, new swallowing issues, a positive COVID test, swallowing difficulties, a fall with head injury, an altercation with another resident, a seizure, and another fall. In each of these events, staff notified only the resident’s daughter‑in‑law, identified as the resident representative, and did not notify the husband or son as emergency contacts/POA. Interviews further confirmed the pattern of non‑notification of the appropriate decision‑makers for this resident. The son reported that the facility did not notify him after any of the resident’s changes in condition and that he learned of these events from the resident representative instead. The husband/POA stated he did not recall being notified by the facility regarding any of the changes in condition and did not know who the facility contacted. The resident representative stated that staff began contacting her instead of the husband and son, sometimes because they did not answer the phone, and acknowledged that this practice bothered the son. The Unit Manager stated that facility nursing staff were required to call the POA and emergency contact for any change in condition and that if a family member onsite was not the POA, staff should still notify the POA. She acknowledged that nursing staff should have contacted the resident’s husband or son regarding the changes in condition, even when the resident representative was present in the facility. For the second resident, who had dementia with behavioral disturbance, chronic respiratory failure with hypoxia, chronic CHF, and hypoglycemia, and who was documented as full code with all interventions, the facility failed to notify a provider when the resident exhibited an acute change in condition. Nursing progress notes documented that in the early morning hours, the resident was mouth breathing with gurgling sounds in the deep throat, had non‑productive coughing, an oxygen saturation of 92% on 3 liters of oxygen, and was uneasily aroused by tactile/verbal stimuli, with abnormal lung sounds including bilateral upper lobe rhonchi and diminished lower lobe sounds. The nurse recorded that the primary care physician was made aware via a non‑emergent in‑house communication log for further evaluation and treatment, and that the oncoming nurse would be informed. Later that morning, the nurse was called to the resident’s room and found the resident unresponsive, with CPR initiated and a code blue performed by EMS, and the resident was pronounced dead. Additional interviews and documentation clarified that the nurse practitioner considered the information placed in the non‑emergent provider logbook inappropriate for that communication channel and stated that staff should have called a facility provider and 911 immediately regarding the resident’s status, rather than using the non‑emergent log. The DON stated that the first time she was made aware of the situation was when the code blue was called and that staff were required to notify a provider for any change in condition; review of the on‑call provider log showed no calls for this resident on the relevant dates. A CNA reported that when she arrived, the resident was not responding or opening her eyes, was coughing with gurgling sounds, and appeared very pale, and that she and another CNA could not obtain a pulse before summoning the nurse and initiating the code blue. The nurse who cared for the resident that morning stated she obtained but did not document vital signs, recalled an oxygen saturation of 88% on 2 liters improved to 92% on 3 liters, noted coughing with inability to expel mucus, and believed the resident was at baseline, so she did not call the on‑call provider and instead wrote in the non‑emergent log. The oncoming nurse stated she was told the resident was not awake or alert enough to receive morning medications, did not see the resident until notified by the CNA that the resident was not breathing, and stated that if a sternal rub was necessary, the nurse performing it should have called the provider. These actions and inactions led surveyors to identify an Immediate Jeopardy related to failure to notify providers and representatives of changes in condition.
Removal Plan
- Provide change in condition (CIC) education to LPN and RN staff, including definition of CIC, appropriate communication to providers, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention.
- Ensure all nurses on duty since the event receive the CIC education and understand their responsibility (DON/designee verification).
- Conduct an initial review of the non-emergent provider communication log process with the provider and administration team to clarify appropriate acuity of notifications.
- Require that changes of condition be reported directly to the provider; restrict the non-emergent log to non-emergent patient requests or medication refills.
- Update the non-emergent provider communication log form to reflect the revised process.
- Place the agency nurse who documented the progress note on administrative leave pending review of care.
- Conduct an in-person meeting with the agency nurse by two nurse managers to review documentation and provide one-on-one education regarding substandard care.
- Notify the agency of the event and investigation involving the agency nurse.
- Assess and document vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) on every resident in the facility.
- Have nurse managers conduct room-to-room visual inspections to verify proof of life and resident stability.
Failure to Follow Physician Orders for Oxygen Therapy and STAT Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to ensure oxygen therapy was administered according to physician orders for Resident #3. The resident had diagnoses including COPD, acute respiratory failure with hypoxia, and acute respiratory failure, with an order for continuous oxygen via nasal cannula at 5.5 LPM to maintain oxygen saturation above 90%. Observations on multiple days showed the portable oxygen device turned off and set at zero, later turned on but set at only 4 LPM, and the resident in bed without a nasal cannula while the concentrator was running at 4 LPM with no cannula attached. A subsequent observation found the portable oxygen device empty and unable to deliver oxygen, with oxygen saturation documented at 84–86% on room air. Staff interviews confirmed that the oxygen should have been on, set to the ordered flow rate, and that the resident required assistance with oxygen therapy. One CNA reported removing the nasal cannula, finding it on the floor, and not replacing it, leaving no nasal cannula readily available for the resident. Resident #3’s care plan identified risks for respiratory complications, falls, and skin breakdown related to respiratory failure, and a change-in-condition note documented episodes of lethargy, mumbling speech, and oxygen saturations as low as 70–81% on 6 LPM of oxygen, with concern for acute exacerbation of congestive heart failure. Despite these documented respiratory issues and the facility’s oxygen concentrator policy outlining proper setup and use, the resident was repeatedly observed without appropriate oxygen delivery equipment in place or with devices not set to the prescribed flow rate. The DON confirmed that oxygen was not provided continuously via nasal cannula at 5.5 LPM as ordered and stated it was her expectation that oxygen be administered per physician orders. The deficiency also involves the facility’s failure to follow physician orders for STAT laboratory tests and a STAT X-ray for Resident #17. This resident had diagnoses including a right femur fracture, DM2, cognitive communication loss, and right hip pain, and developed severe left knee pain with swelling and decreased range of motion. An after-hours provider ordered STAT CBC, CMP, CRP, and a STAT X-ray of the left knee. Physician orders documented these STAT tests and imaging for severe left knee pain. However, the resident’s daughter reported that when she arrived the next day, she was told the labs and X-ray had not been completed because the orders were not documented correctly. The DON confirmed that the STAT orders for labs and X-ray were not documented correctly, which led to a delay in completing them, and acknowledged that the labs and X-ray should have been obtained immediately per the physician’s orders but were not.
Failure to Provide Ordered Surgical Wound Care Resulting in Infected Abdominal Incision
Penalty
Summary
The facility failed to provide physician-ordered surgical wound care to a resident with an abdominal incision following digestive system surgery. Facility policy dated 09/15/25 required safe and effective wound care, adherence to specific orders for surgical wounds, and daily monitoring of wounds and dressings for complications or decline. The resident was admitted on 09/03/25 with diagnoses including surgical aftercare following digestive system surgery, incisional hernia without obstruction, and unspecified intestinal obstruction. Physician orders dated 12/17/25 directed that the abdominal wound be cleansed with wound cleanser, patted dry, packed with optical AG rope, and covered with a foam dressing every day shift from 12/17/25 through 12/23/25. The Treatment Administration Record for 12/17/25 through 12/23/25 showed the wound care as completed every shift as ordered. However, nursing progress notes dated 12/22/25 documented that the midline abdominal surgical wound dressing was changed that day, and that the last dressing change had actually occurred on 12/18/25, indicating that ordered wound care had not been completed between 12/18/25 and 12/22/25. At that time, increased drainage with thick brown serosanguineous fluid and increased redness around the wound were observed, and the wound nurse was notified of the worsening appearance. A communication form entry dated 12/22/25 recorded a reddened abdominal incision with purulent drainage, with the resident reporting the dressing had not been changed since 12/17/25. A wound culture subsequently tested positive for gram negative and gram positive bacteria, and the resident’s daughter was notified of the missed treatments and positive culture. In interviews, the daughter confirmed being told that the bandage had not been changed for several days, the Infection Preventionist/Unit Manager acknowledged that scheduled wound care was missed from 12/18/25 through 12/22/25 and that the incision became inflamed, reddened, and MRSA-positive, and the DON confirmed that the wound care was not completed per physician orders.
Unsecured Medication and Treatment Carts on 300 Unit
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to properly secure medication and treatment carts on the 300 unit. On 03/17/26 at 2:39 PM, the wound care treatment cart was observed unlocked and open, containing wound care supplies, tweezers, topical creams, and scissors, with no nursing staff present in the area. Later that same day at 3:10 PM, the medication cart on the 300 unit was also observed unlocked and open, containing multiple medications including Buspirone, Glipizide, Mirtazapine, Venlafaxine, Carbamazepine, Gabapentin, Colace, eye drops, and lancets, again with no nursing staff present nearby. During an interview on 03/17/26, an LPN acknowledged that she was responsible for both the treatment and medication carts and confirmed they were unlocked and open. She stated that the carts should be locked when not in use and that medication carts should never be left open because a resident could ingest medications not prescribed to them, resulting in illness. On 03/18/26, the DON stated that staff should never leave a medication or treatment cart unlocked and unattended, and that her expectation is that all such carts are locked when not in use. She further stated that if a medication or treatment cart were left unlocked, residents could access the contents and sustain injury.
Incomplete and Inaccurate Medical Record Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for two residents. For one resident with a midline abdominal surgical wound, the Treatment Administration Record (TAR) for a specified period showed that surgical wound care was documented as completed every shift per physician orders. However, a nursing progress note later documented that on one date the dressing was changed and the old dressing was still dated several days earlier, indicating that wound care had not been performed as ordered during that interval. The same note described increased drainage with thick brown serosanguineous fluid and increased redness around the surgical site, and the wound nurse was notified of the worsening appearance. A communication form entry further documented that the abdominal incision was reddened with purulent drainage, that the resident reported the dressing had not been changed for several days, and that a wound culture was positive for gram negative and gram positive bacteria, confirming an infected surgical wound. The DON stated that it was her expectation that wound care be accurately documented and performed according to physician orders and confirmed that the TAR documentation showing wound care as completed on the specified dates was not accurate. For another resident who experienced a change in condition, the Electronic Health Record (EHR) did not contain documentation of vital signs taken in the early morning following that change. Record review showed that vital signs obtained at a specific time were not entered into the EHR after the change in condition occurred. In an interview, the DON confirmed that the resident’s vital signs were not documented in the EHR after the change in condition and acknowledged that they should have been documented. These findings show that the facility failed to ensure that medical records, including treatment documentation and vital signs following a change in condition, were complete and accurate for both residents.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement an adequate baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed the resident was admitted with multiple diagnoses, including a right femur fracture, type II diabetes mellitus, cognitive communication loss, and right hip pain. The baseline care plan, dated the day after admission, addressed only skin integrity of the right hip after surgery and did not include any other care areas or diagnoses. During an interview, the Unit Manager stated that a complete baseline care plan should include ADLs, fall risk interventions, wounds and skin care, advanced directives, and specialized care such as diabetic management. The Unit Manager confirmed that the resident’s baseline care plan was not complete and did not meet these expectations. The incomplete and inaccurate baseline care plan resulted in the absence of documented interventions for several of the resident’s admitting conditions.
Misappropriation of Resident Property by Transport Driver
Penalty
Summary
A deficiency occurred when a transport driver took money from a resident, violating the facility's Code of Conduct, which prohibits staff from asking for or accepting tips, gifts, loans, or monetary transactions from residents or their family members. The resident, who was cognitively intact according to a recent assessment, reported that during a trip to the bank, the driver repeatedly mentioned needing money and recounted stories about his family, which led the resident to feel inclined to loan the driver $100. The driver assured the resident that he would repay the money with his next paycheck, but after about a month without repayment or contact, the resident attempted to reach the driver through facility staff. The incident came to light when the resident informed the transport clerk about the loan and provided the driver's name and description. Upon investigation, the driver admitted to taking the money but claimed it was given as a tip. The facility's records confirm that the driver accompanied the resident into the bank and engaged in conversations that influenced the resident to provide the money. The facility's policy clearly states zero tolerance for any form of misappropriation or exploitation of resident property, and this event constituted a direct violation of that policy.
Failure to Report Medication Error to State Agency
Penalty
Summary
The facility failed to report a medication error involving a resident with diagnoses of morbid obesity and Type 2 diabetes mellitus. According to the facility's Abuse Prohibition Policy, all allegations of abuse, neglect, or incidents resulting in serious bodily injury must be reported immediately or within specified timeframes. Despite this policy, the medication error was not reported to the State Agency as required. Record review showed the resident had active physician orders for Mounjaro (tirzepatide) and Emgality for diabetes and migraine prophylaxis, respectively. During an interview, the Administrator confirmed that the medication error was not reported and attributed the failure to high staff turnover, the Director of Nursing being on leave, the training of a new DON, and ongoing staffing instability at the time of the incident.
Significant Medication Error: Duplicate Dose of Mounjaro Administered
Penalty
Summary
Staff failed to prevent a significant medication error when a resident with morbid obesity and Type 2 diabetes mellitus received two doses of Mounjaro (tirzepatide) 12.5 mg within 24 hours, contrary to the physician's order for once-weekly administration. The error occurred when staff administered Mounjaro instead of the resident's scheduled Emgality injection for migraine prophylaxis. The medications were stored together in the same refrigerator and appeared similar, contributing to the confusion. The electronic medication administration record (MAR) continued to prompt for Mounjaro administration, which also contributed to the error. The nurse who administered the medication did not read the medication label carefully, leading to the administration of the wrong drug. Following the error, the nurse notified the resident, nurse practitioner, guardian, and charge nurse, and Poison Control was contacted. The nurse practitioner ordered enhanced monitoring, including holding the resident's oral antidiabetic medications and increasing blood glucose checks. However, documentation showed that staff only continued routine blood sugar checks and did not increase monitoring or document reassessment for side effects or symptoms beyond the resident's baseline schedule. There was no nursing narrative assessing for symptoms or evidence of monitoring for adverse effects as recommended.
Unattended and Unlocked Medication Cart Found on Hallway
Penalty
Summary
A medication cart was observed on the 200 Hall with the top drawer unlocked and unattended, allowing potential unauthorized access to medications. No staff were present in the immediate area at the time of observation. Facility policy requires all medications to be secured at all times, with medication carts locked when not in the direct possession of licensed staff, and controlled substances stored in a separately locked compartment. The unattended cart contained narcotics in a locked box, while other resident medications were accessible in the unlocked drawers. During an interview, a registered nurse confirmed she had left the cart unlocked while stepping into a resident's room, acknowledging that this could allow a resident to access medications not prescribed to them. The interim Director of Nursing also stated that her expectation is for all medication carts to remain locked at all times to prevent unauthorized access. The incident involved one medication cart and did not specify any particular resident's medical history or condition at the time.
Failure to Report and Repair Broken Wall in Resident Room
Penalty
Summary
Staff failed to report or repair a broken wall in a resident's room, resulting in an environment that was not safe, functional, sanitary, or comfortable. The broken wall, which included a hole, was observed during a facility visit. The resident stated that the hole had been present since moving into the room and had not been reported to staff. Review of facility work orders confirmed that the issue had not been documented or addressed by staff. Interviews with facility staff, including a CNA, the Maintenance Director, the DON, and the Administrator, revealed that none were aware of the broken wall prior to the survey. Staff indicated that maintenance issues are expected to be reported through the facility's Equipment Lifecycle System (TELS), but this process was not followed in this instance. The Maintenance Director noted the damage was likely caused by water and acknowledged the potential for mold and pest entry. The Administrator stated that quality of life rounds had not yet included the affected room and that maintenance rounds alone were insufficient to identify all issues.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to a physician's order and professional standards of practice for medication administration for a resident with a gastronomy tube (g-tube). The resident, diagnosed with traumatic brain injury, cerebrovascular accident, and transient ischemic attack, had specific physician orders to flush the g-tube with water before and after each medication pass and between each medication administered via the g-tube. However, on a specific date, a registered nurse (RN) administered three medications simultaneously via a 50 mL syringe into the resident's g-tube without flushing the tube before or after the administration, contrary to the physician's orders. The incident was captured on video by the resident's Power of Attorney, who had installed a camera in the resident's room. The Medication Administration Record confirmed that the RN administered dantrolene, donepezil, and Tylenol at the same time. A peer-reviewed article from the National Institute of Health emphasized the importance of administering each medication separately and flushing the tube with water before and after each medication. During an interview, the Director of Nursing acknowledged that the RN did not follow the required procedures for medication administration via the g-tube.
Failure to Notify Physician of Missed Seizure Medications
Penalty
Summary
The facility failed to notify the physician for a resident when they did not immediately inform the physician of the resident's missed seizure medications. The resident, who had a history of traumatic brain injury, seizures, and other severe conditions, missed doses of levetiracetam on multiple occasions. This resulted in the resident experiencing breakthrough seizures and low blood oxygen saturation, leading to an emergency hospital transfer. The resident's medication administration record showed that the evening dose of levetiracetam was not administered on one day, and both morning and evening doses were missed the following day. Despite the medication being available in tablet form in the facility's Omnicell, staff did not administer it or notify the physician about the missed doses. The resident's condition deteriorated, and they were transferred to the hospital after experiencing multiple seizures. The facility's records did not contain documentation explaining why the medication was not administered or why the physician was not notified. The Director of Nursing confirmed that the medication was not available in the prescribed liquid form but was available in tablet form, which could have been used. The failure to notify the physician and administer the medication as ordered led to a delay in treatment for the resident.
Failure to Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to administer levetiracetam, an anti-seizure medication, to a resident on three occasions as per the physician's order. The resident, who had a history of traumatic brain injury, seizures, and a persistent vegetative state, missed doses on the evening of 12/14/2023 and both morning and evening of 12/15/2023. This led to the resident experiencing adverse side effects, including breakthrough seizures, which required emergency medical intervention. The medication administration record (MAR) confirmed that the doses were missed, and the electronic medical record (EMR) indicated that the resident's condition deteriorated, with unstable vitals and seizures occurring intermittently. The facility's investigation revealed that the medication was not available in the medication cart, although it was accessible in the facility's automated medication storage system (Omnicell) in tablet form, which could have been crushed and administered via the resident's G-Tube. Interviews with the Director of Nursing (DON) and staff statements corroborated that the medication was not administered due to its unavailability in the cart. The DON acknowledged that the medication was available in the Omnicell and could have been used as an alternative. The facility initiated an investigation and corrective actions following the incident, but the deficiency resulted in significant harm to the resident due to the missed doses of the critical medication.
Failure to Serve Food Under Sanitary Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions in accordance with professional standards of food service safety. Multiple residents reported that their food was often served cold and unappetizing. Specific instances included a resident stating they were served raw chicken on several occasions and another resident mentioning that breakfast was cold when delivered to their room. Observations and interviews revealed that the internal temperatures of both hot and cold foods were not maintained at safe levels, with hot foods being served below 135°F and cold foods above 41°F. For example, a cheese quesadilla measured 101.9°F, seasoned potato wedges at 96.0°F, pineapple tidbits at 60.5°F, and a cup of lemonade/juice at 49.8°F. Additionally, egg salad sandwiches and Italian sub sandwiches were also found to be above the recommended temperature for cold foods. The Dietary Manager (DM) acknowledged the temperature discrepancies and noted that the food cart often sat in the halls for extended periods before staff delivered meals to residents' rooms, which could contribute to the temperature issues. The DM verified that hot foods should be served hot and cold foods should be served cold unless otherwise requested by the resident. The failure to monitor and maintain appropriate food temperatures is likely to result in foodborne illnesses and could affect all 115 residents in the facility.
Failure to Ensure Meals are Palatable and at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, unappetizing, and sometimes even raw. Specific instances included a resident stating that the food was not always hot and arrived cold to her room, another resident mentioning that the food was regularly cold and unappetizing, and another resident stating that the food was often unidentifiable and tasted awful. Additionally, one resident reported being served raw chicken on several occasions, and another resident frequently requested alternative meals due to the poor quality of the regular meals, although the alternatives were also sometimes unsatisfactory. An observation of a test tray revealed that the green beans were unseasoned and cold, the cheese quesadilla was cold with unmelted cheese, and the pineapple pieces and beverage were warm. The Dietary Manager (DM) acknowledged that residents had complained about the food carts sitting in the halls for extended periods before meals were delivered to their rooms, which could contribute to the complaints of cold food. This deficiency in meal service reduces residents' ability to enjoy their meals and may negatively impact their quality of life. The report highlights the facility's failure to maintain meal quality standards, as evidenced by the residents' consistent complaints and the observed condition of the test tray meal.
Inaccurate Insulin Use Information in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments included accurate insulin use information for two residents. For one resident, the quarterly MDS assessment indicated that the resident received seven insulin injections during the seven-day look-back period. However, a review of the resident's physician's order summary and Medication Administration Record (MAR) for the same period showed no orders or administration of insulin. Similarly, for another resident, the quarterly MDS assessment also indicated seven insulin injections during the look-back period, but the physician's orders and MAR did not support this information. During an interview, the MDS nurse confirmed that neither resident had an order for the administration of insulin during the look-back period and acknowledged that staff should not have indicated insulin administration on the MDS assessments. This discrepancy in the MDS assessments could likely result in residents not receiving the most optimal and personalized care required to meet their highest practicable outcomes.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to properly store medications in medication carts, resulting in loose medications being found under the medication cards. Specifically, during an observation of the 400 hall medication cart, a loose round, white tablet was found under the medication cards. Similarly, during an observation of the 300 hall medication cart, multiple loose medications were found, including one white oval tablet, two pink oval tablets, one liquid capsule, and two white circular tablets. The Director of Nursing (DON) confirmed that loose medications are not allowed to be stored in the medication carts and that staff should check for loose medications daily.
Failure to Accommodate Dietary Preferences and Needs
Penalty
Summary
The facility failed to accommodate the food preferences and dietary needs of two residents, leading to frustration and emotional distress. Resident #36 consistently did not receive the meals she ordered, despite submitting her order sheet daily. On one occasion, she was served chicken fried steak instead of the Salisbury steak she had requested, causing her to become visibly upset and cry. The Dietary Manager confirmed that the kitchen had run out of Salisbury steaks but was unsure why some residents still received them. This indicates a lack of proper meal planning and communication within the dietary department. Resident #49, who follows a vegetarian diet, was served a meal containing meat, contrary to her dietary preferences. The Dietary Manager was unaware of her vegetarian diet and stated that the resident usually ordered a cheese quesadilla. The failure to provide a vegetarian meal was attributed to a miscommunication between the CNA and the cook. This oversight highlights a significant gap in the facility's ability to adhere to residents' dietary preferences and ensure their nutritional needs are met.
Failure to Provide Scheduled Showers and Timely Call Light Response
Penalty
Summary
The facility failed to support residents in activities of daily living (ADLs) by not offering showers according to a pre-planned and agreed-upon schedule and not answering call lights in a timely manner. Resident #309, who was cognitively intact and required substantial assistance with ADLs, reported not having a shower since admission and not knowing her shower schedule. The Director of Nursing (DON) confirmed that Resident #309's shower schedule was every Thursday and Sunday, but records showed inconsistencies in offering showers. Similarly, Resident #2, who also required assistance with ADLs, did not receive showers as scheduled due to staff shortages, as confirmed by the DON. Records indicated that Resident #2 was not offered showers on multiple scheduled days in March 2024. The facility also failed to respond to call lights in a timely manner. Resident #309, who required substantial assistance for toileting and transfers, reported that staff did not come to assist her after pressing her call light, leading her to go to the bathroom on her own after waiting for about an hour. Another resident, #73, was observed waiting 22 minutes for assistance after activating the call light. The DON stated that staff should answer call lights within 10 to 15 minutes, acknowledging that 15 minutes would be too long to wait for care. These deficiencies are likely to negatively impact resident safety, comfort, and timely incontinence care.
Failure to Follow Menu and Dietary Preferences
Penalty
Summary
The facility failed to serve food according to the presented menu, which is a repeat deficiency. During an interview, a resident stated there was not much variety, and the menu was not followed. On a specific date, the posted lunch menu included country fried steak with mushroom gravy or fish tacos, along with other side items. However, during a meal observation, a resident was served Salisbury steak, mashed potatoes with brown gravy, and a small bowl of salad, which did not match the posted menu. The resident's meal ticket also indicated Salisbury steak, confirming the discrepancy between the menu and the served meal. Another resident, who is vegetarian, was served Salisbury steak, mashed potatoes with brown gravy, and a small bowl of salad, despite their meal ticket indicating a cheese quesadilla, seasoned green beans, and pineapple tidbits. The resident's dietary preference for a vegetarian diet was documented in their records. The Dietary Manager acknowledged that sometimes substitutions are made due to out-of-stock items but was unsure why the incorrect meals were served. The Dietary Manager also stated that the Certified Nursing Assistant did not specify the correct tray for the vegetarian resident.
Non-Functional Call Light
Penalty
Summary
The facility failed to ensure a resident's call light was functioning as intended. During an observation, the resident was found with a call light button attached to her bedside commode, which did not work when pressed. The resident reported that the call light had been non-functional for several days and that she had informed multiple staff members, but no action had been taken. A review of the facility's maintenance work orders revealed no record of an open or resolved work order for the call light. The Administrator confirmed that the call light was in need of repair and acknowledged that no work order had been entered.
Failure to Properly Document and Label Oxygen Therapy
Penalty
Summary
The facility failed to meet professional standards of care for a resident requiring oxygen therapy. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia following a stroke, asthma, chronic diastolic heart failure, obstructive sleep apnea, and other pulmonary embolism, was observed using oxygen through a nasal cannula. However, the oxygen tubing and humidifier were not labeled with the date of the last equipment change. Additionally, the resident's medical record did not contain physician orders for oxygen therapy or for changing the oxygen tubing and humidifier. During interviews, staff confirmed that the oxygen equipment should be labeled with the date of the last change and that the resident's medical record should include physician orders for oxygen therapy and equipment changes. The Director of Nursing acknowledged that the resident was admitted on oxygen therapy without the necessary physician orders in her chart and that the facility's policy was to enter these orders at the time of admission. The failure to follow these protocols was identified as a deficiency in the facility's care standards.
Latest citations in New Mexico
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
Surveyors found that a treatment cart containing drugs and biologicals on two units was left unlocked and unattended, with no staff present. An LPN confirmed the cart belonged to the treatment nurse, who was not on the unit at the time, and acknowledged that it was unlocked. A consultant nurse later stated that treatment carts are required to be locked when not in use.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with impaired cognition and a low BIMS score had a family member designated as POA for health care and related decisions. The POA became concerned about the resident’s care and requested the resident’s medical records but did not receive them. Nursing notes documented the POA’s expressed frustration about still waiting for the records. The Medical Records staff required the POA to complete authorization paperwork twice, stated the first set was completed incorrectly, and reported that corrected paperwork was not returned until after the resident’s death, at which point additional documentation was required. Staff acknowledged that the POA was authorized to act on the resident’s behalf and that, unlike a resident’s own oral request, the POA’s request was not honored without extra paperwork, resulting in the POA never obtaining the records.
A resident’s care plan was not revised to include a family member’s request that a specific housekeeper have no contact with or provide care to the resident in a secure unit, despite the family reporting that this housekeeper had previously caused the resident to fall and had been verbally restricted from working around the resident by prior and current leadership. The housekeeping supervisor and the housekeeper confirmed that the housekeeper no longer worked in the secure unit or with the resident, but the MDS nurse reported she was never informed of this change and therefore did not update the care plan, and the ADON confirmed the care plan lacked this information.
The facility failed to maintain required postings of Ombudsman contact information in accessible areas for residents and their representatives. Surveyor observations found that Ombudsman information was not posted in the facility and that, when present, it was placed on the side of a refrigerator in the Activities Room rather than in a clearly visible location. The Administrator reported that Ombudsman posters had been removed to allow painting and were not re-posted afterward. This deficiency had the potential to affect all residents in the facility, as they and their representatives would not be aware of how to contact the Ombudsman about concerns.
The facility did not maintain the required 18 months of posted nurse staffing records. Surveyors observed that only the current day’s staffing information was posted in the lobby, and during interviews the new DON reported uncertainty about whether historical staffing records were kept. The Administrator later stated that the facility was trying, but unable, to access prior posted staffing information. As a result, residents and the public could not review the required historical nurse staffing data.
The facility did not consistently provide adequate evening and nighttime snacks to residents who requested them. A resident reported that snacks were rarely offered at night and that staff sometimes said none were available. Observation of the nourishment refrigerator showed minimal, often unlabeled items, while CNAs and the Activities Assistant described limited quantities of milk, yogurt, shakes, and sandwiches for multiple residents on each hall. The DM and DON confirmed that snacks were now restricted to those ordered by the RD, with no general snacks left accessible and no staff access to the kitchen at night, resulting in residents without prescribed snacks frequently being told there were not enough snacks and staff occasionally buying snacks themselves.
A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
A resident with COPD, acute respiratory failure, pulmonary fibrosis, and recent hospitalization for UTI and sepsis returned from the hospital on palliative care with an order for continuous O2 at 2 L/min via nasal cannula. After arrival, staff removed the ambulance’s portable O2 and attempted to use the facility’s O2 concentrators, which were ineffective, while the resident was restless and grabbing at the air. The resident’s daughter reported a period without O2 while staff tried different concentrators and searched for equipment, estimating about 15 minutes before a portable O2 tank was brought back, at which point the NP pronounced the resident deceased. The DON later questioned why a portable O2 tank had not been used when the concentrators failed, and the NP stated the concentrator in use at the time of her assessment was not working properly.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Unlocked and Unattended Treatment Cart on Two Units
Penalty
Summary
The deficiency involves the facility’s failure to secure a treatment cart containing drugs and biologicals on the 500 and 600 units, affecting all 27 residents identified on those units by the census list provided by the Administrator on 04/29/26. On 04/29/26 at 8:40 a.m., surveyors observed at the nurses’ station that a treatment cart on the 500/600 unit was left unlocked and unattended, with no staff present. During an interview at 8:44 a.m., an LPN confirmed that the treatment cart was unlocked and identified it as the Treatment Nurse’s cart, noting that the Treatment Nurse was not on the unit at that time. On 04/30/26 at 2:06 p.m., the facility’s consultant nurse stated that treatment carts are supposed to be locked when not in use. The report states that this deficient practice could result in residents obtaining medication not prescribed to them, resulting in adverse side effects. No specific resident medical histories or conditions at the time of the deficiency are described in the report.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Failure to Provide Resident’s Legal Representative Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with access to the resident’s medical records upon request. The resident had impaired cognitive function, an impaired thought process, and a Brief Interview for Mental Status (BIMS) score of 5, and had designated a family member as Power of Attorney (POA) with authority over long-term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. Nursing progress notes documented that the POA approached the Assistant Director of Nursing and staff, stating they were still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the Medical Records (MR) staff required the POA to complete paperwork to obtain the resident’s medical records, even though MR acknowledged that the POA was legally authorized to act on the resident’s behalf and that the resident did not have the capacity to request records independently. MR reported giving the POA the required forms twice, stating the first set was filled out incorrectly and that the POA needed to complete them again. MR further stated that the POA did not return the corrected paperwork until after the resident’s death, at which point the facility required additional paperwork to release records following a resident’s passing. MR also stated that if a resident personally requested their own medical records, an oral request would be sufficient and no paperwork would be required. Despite the POA’s requests and authority, the POA never received the resident’s medical records. The facility’s policy on determining validity of authorization for release of protected health information required the Medical Records Director to determine whether an authorization was needed for disclosure, but the records were not provided to the POA prior to the resident’s death.
Failure to Update Care Plan With Family’s Restriction on Specific Staff Contact
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect a family member’s request regarding staff contact. Record review showed that the resident’s care plan, last revised on 06/26/25, did not include the family member’s request that a specific housekeeper not have contact with or provide care to the resident in the secure unit. The family member reported that this housekeeper had caused the resident to fall in her room, that the housekeeper was not a CNA in the secure unit, and that the previous Administrator and DON had informed the family member that the housekeeper would no longer work in the secure unit. The family member also stated that this information had been communicated to the current Administrator and DON when they started working at the facility. Interviews with facility staff confirmed that the housekeeper no longer worked in the secure unit and was not to have contact with or provide care to the resident, but this change was not documented in the resident’s care plan. The housekeeping supervisor stated that the housekeeper did not work in the secure unit due to the family member’s wishes. The housekeeper confirmed she no longer worked in the secure unit and was not to be in contact with or care for the resident. The MDS nurse, who is responsible for entering information into residents’ care plans, stated that staff had not informed her of the family member’s request and acknowledged that any changes to a resident’s care should be entered into the care plan. The ADON also confirmed that there was nothing in the care plan reflecting the family member’s wishes and stated that it should have been included.
Failure to Properly Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post the required Ombudsman contact information in areas accessible to residents and their representatives, as required by regulations mandating that names, addresses, and telephone numbers of pertinent State agencies and advocacy groups be posted along with a statement that residents may file a complaint with the State Survey Agency. On 04/29/26 at 9:35 AM, an observation of the facility revealed that staff did not have the Ombudsman information posted. Later that morning at 10:00 AM, an observation of the Activities Room showed that staff had placed an 8.5 x 11-inch paper with Ombudsman information roughly at eye level on the side of a refrigerator, rather than in a more generally visible or designated posting area. On 04/30/26 at 12:47 PM, the Administrator stated in an interview that the facility had taken down the Ombudsman posters in order to paint and confirmed that staff failed to put the Ombudsman posters back up after the painting was completed. This deficiency had the potential to affect all 89 residents identified on the census list provided by the Administrator on 04/29/26, as residents and their representatives would not be aware of how to contact the Ombudsman about concerns they have.
Failure to Maintain 18 Months of Posted Nurse Staffing Records
Penalty
Summary
The facility failed to retain 18 months of records for the daily posted nurse staffing information, affecting all 89 residents as identified on the census list provided by the Administrator on 04/29/26. During an observation of the front lobby at 8:54 AM on 04/29/26, surveyors noted that the current day’s nursing staff information was posted. However, in a subsequent interview at 8:58 AM, the DON, who reported being new to the position, stated she was unsure whether the facility maintained 18 months of the posted nursing staff information. In a later interview on 04/30/26 at 12:47 PM, the Administrator stated that the facility was attempting to obtain access to the historical posted nursing staff information but had been unable to do so. Because the facility did not have 18 months of posted staffing records available, residents or the public would not have access to review the required historical nurse staffing information.
Failure to Provide Adequate Evening and Nighttime Snacks to Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences for evening and nighttime snacks. One resident reported that snacks were not offered very often, especially at night, and that when he asked for a snack he was sometimes told there were none available. Observation of the locked unit nourishment refrigerator showed only one labeled sandwich dated the previous day, along with unlabeled and undated yogurts, sandwich items in a white shopping bag, and two undated and unlabeled metal tumblers. RN staff stated that the snacks in the white shopping bag were intended for all residents who wanted a snack. Multiple CNAs reported that there were not enough snacks at night, noting that the kitchen was locked, and that only a small number of milk cartons, yogurts, supplement shakes, and a few sandwiches were available despite there being about 22 residents per hall. The Dietary Manager stated that snacks were put out three times a day only according to Registered Dietician orders, and that not everyone received a snack; snacks were not left in the refrigerator for residents, and staff could not access the kitchen at night. The DON reported that the kitchen previously put out a lot of snacks but stopped due to waste and cost, and that snacks were now limited to those prescribed by the Registered Dietician. Staff interviews, including CNAs and the Activities Assistant, indicated that residents without prescribed or labeled snacks frequently asked for snacks and were sometimes told there were not enough, leading staff to purchase snacks themselves or use vending machines to meet residents’ requests. These observations and interviews show that residents who wanted or needed snacks, including those with diabetes, did not have consistent access to adequate evening and nighttime snacks.
Unauthorized Discontinuation of Glaucoma Eye Drops
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when an ordered glaucoma eye drop medication for one resident was discontinued without a physician’s authorization. The resident was admitted with diagnoses including cerebral infarction, dementia, and glaucoma. Physician orders showed multiple start dates for Dorzolamide HCI-Timolol Maleate eye drops for both eyes, to be administered in the morning, evening, and at 5:00 a.m., with discontinuation dates entered in the record. Review of the medication administration record for March revealed that the resident did not receive the ordered eye drops because an active order was no longer available. Further review of nursing progress notes documented that the Dorzolamide HCI-Timolol Maleate eye drops had been discontinued by the facility on a specific date without a physician’s order to do so. During interviews, the administrator acknowledged that the eye drops were discontinued by accident and confirmed there was no physician authorization for discontinuation. An LPN reported that she accidentally discontinued the eye drops and did not realize the error for five days, at which point she recognized that the medication had been stopped in error. The DON also stated that the eye drop medication should not have been discontinued by accident because there was no physician order to discontinue it.
Failure to Provide Continuous Oxygen per Physician Orders Due to Equipment Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous oxygen (O2) as ordered for a resident with significant pulmonary conditions. The resident had diagnoses including fracture of the left femur, COPD, acute respiratory failure, and pulmonary fibrosis, and had recently been hospitalized for a UTI and sepsis. Hospital records indicated diagnoses of pulmonary fibrosis, sepsis, and UTI, with a recommendation for palliative care. Upon discharge back to the facility, the physician’s order specified O2 at 2 liters per minute continuously via nasal cannula. Nursing progress notes documented that the resident arrived at the facility on a stretcher wearing 2 liters of O2, was restless and grabbing at the air, and was placed in bed while staff attempted to transition her from the ambulance’s portable O2 to the facility’s O2 concentrator. According to the nursing notes and interviews, the first O2 concentrator was ineffective, and the resident was temporarily placed on a portable O2 tank with a mask. The facility nurse then attempted to use various connectors and obtained another O2 concentrator, which also did not work properly. The resident’s daughter reported that once staff removed the ambulance’s portable O2 and attempted to use the facility concentrator, there was a period during which the resident was not on O2 while staff searched for another concentrator, and that it took approximately 15 minutes for the nurse to return with a portable O2 tank, by which time the nurse practitioner (NP) stated the resident had died and did not need O2. The DON later stated he questioned why a portable O2 tank had not been used when the concentrators were not working to maintain continuous O2 per the physician’s order. The NP confirmed that when she arrived, the resident was on O2 from a facility concentrator that was not working properly and that she did not know how long it had been malfunctioning before the resident’s death.
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